Expert Q&A: How can you motivate someone to exercise to improve their mental health?

Jasper Smits, Ph.D., is co-director of the Anxiety Research and Treatment Program at Southern Methodist University (SMU) and the co-author (with Michael Otto) of Exercise for Mood and Anxiety: Proven Strategies for Overcoming Depression and Enhancing Well-Being (Oxford University Press, 2011). Minding Our Bodies talked to Jasper Smits about his research on exercise interventions for mental health and his techniques for motivating behaviour change.

Q: Tell us about your research background and what led you to publish your recent book.

A: I’ve been at SMU since 2004, where my work focuses on developing interventions for anxiety related problems. Much of our work has been around cognitive and behavioural treatments, and learning more about how they work and for whom they work. We’ve looked at both mediators and moderators, including psychosocial strategies as well as more pharmacological approaches.

When we started looking at exercise interventions, I learned quickly that there was a large literature, with a lot of work already being done. People such as Madhukar Trivedi here in Dallas and James Blumenthal at Duke had done large studies looking at exercise, primarily for mood disorders. When we pulled together the literature in a meta-analysis, we were really pleased to see that exercise was an effective intervention for mood, and particularly for people who have low to moderate levels of major depressive disorders. Exercise offers some benefits that are similar or comparable to what you can get with pharmacotherapies and established psychotherapies, such as cognitive behavioural treatment.

We’ve since done some studies to look at how it might work for anxiety and depression, and we’ve looked at more psychosocial mechanisms — things such as people learning to tolerate the stress better, if you can think of exercise as a stressor. You teach people to handle stress better with exercise, and that’s essentially what we do in psychotherapies for the anxiety and mood disorders as well.

The literature shows that these behavioural and cognitive approaches to anxiety disorders are effective, but it’s really hard to push them out into clinical practice, so the dissemination has been slow. We thought that an effective intervention like exercise may offer some appeal for people who either don’t have access to more traditional treatments or maybe don’t have an interest in these treatments. So that was our starting point for the book.

Q: Your work focuses primarily on the effectiveness of exercise for people with mild and moderate depression or anxiety. What do researchers know about the effects of exercise on other disorders, such as severe depression or schizophrenia?

A: The research is less well developed there, but when we review the literature, we see promise. Initial good work, for example, in panic disorder. There is also some research now on obsessive-compulsive disorder, but it’s limited to a small number of studies and studies with small sample sizes. The effects look good, but it would be a bit of a stretch at this point to say we have a lot of confidence in them. So, when I feel confident saying that exercise is effective for mild to moderate forms of major depressive disorder, that confidence is based on a large number of studies that have demonstrated positive results. Is it effective for more severe forms? We don’t know. We can’t say that it isn’t. It’s just that the research hasn’t been performed yet.

Q: What about addictions or substance dependence?

A: Same thing there. We actually have an ongoing study looking at exercise for smoking cessation. This was prompted by some initial findings by Bess Marcus and colleagues that show that exercise can be used for smoking cessation. We’re testing that right now on a four-year trial. I think there are similar trials ongoing for alcohol, and there’s a large study by the National Institute on Drug Abuse looking at exercise as an intervention for illicit drug use. So, work is being done and there have been initial promising effects. Now the large-scale trials are being conducted, but it will be a few years before we know whether exercise is a viable intervention for those problems.

Q: You’re a member of the Scientific Advisory Board for the Anxiety Disorders Association of America. Broadly speaking, is exercise well recognized or widely accepted among your colleagues as a treatment approach?

A: This is a really great question. If you do a survey — we haven’t done this, so I’m speculating here, mostly based on conversations I’ve had with people at ADAA — I think few people would deny the effects of exercise for anxiety disorders. If you ask the question, ”Do you think it’s effective?” people say, ”Sure, I think it makes sense to integrate it in treatment, either to have it there alongside pharmacotherapy or alongside psychotherapy.” You don’t hear a lot of people say, “No, don't use it.” But when you ask the question, is it accepted and do people actually prescribe it? I think fewer people do. We’re used to reaching for established treatments — a psychiatrist might be more likely to stick with pharmacological approaches, and many psychologists who follow the literature might reach for cognitive behavioural approaches and not necessarily for exercise. So, I think it’s recognized, but it’s not considered a standard intervention.

Q: Is it fair to assume that exercise doesn’t figure prominently in published professional practice guidelines?

A: That’s right. It doesn’t.

Q: What prompted you to move from pure research into creating practical tools, like your earlier guidebook for clinicians and the companion workbook?

A: Growing up, so to speak, in an environment where people speak highly of behavioural and cognitive treatments, I was surprised initially to see how little these approaches are actually used in clinical practice. There are a number of surveys that show that among people who suffer from an anxiety disorder and go for treatment, only about one in five receive an established treatment or an efficacious treatment. That was just shocking to me, to see that we have these good interventions, yet most people are not receiving them.

I think we should do a better job of disseminating these established treatments, but also I think that we need to start thinking about complementary approaches. We’re not saying, let’s think of exercise as an alternative to psychotherapy or as an alternative to medications, but you need more approaches to reach all the people in need, and exercise really does fit in there.

When we wrote our first two books, a therapist guide and a client workbook — as you know, it’s a set of books that go together — they were really for people who are working in clinical settings and who could use our guidebook to work with patients who are interested in making exercise part of their treatment. The therapist can use the guidebook to prescribe and to work with a patient during their sessions and then the patient can use the client workbook to do their homework in between sessions. That was our first step, to get exercise into clinical practice.

Our newest book, Exercise for Mood and Anxiety, is targeted to consumers. We realized that many people who suffer from anxiety or mood problems don’t actually go to see a psychiatrist or a psychologist or a mental health care provider, yet they still obviously need help and they may favour a self-help approach. When we examined the self-help literature, we did find a number of books on exercise. But we felt there was a gap in providing a self-help book that talks about how to work with motivational barriers and how to get people to actually use exercise to overcome mood and anxiety problems. The book we wrote is not just about, “This is what you need to do, and this is the number of sessions, this is the intensity, this is the dose,” because there a lot of books on exercise prescription. Our book focuses on how you can get more motivated to exercise, what you can do during exercise to make it more pleasant, and what you can do after exercise to help you make it more of a habit.

Q: Could you briefly explain the concept of “prescribing” exercise?

A: This is tricky — and I think it’s true for many of our treatments, including the cognitive behavioural treatments, maybe to a lesser extent for our pharmacotherapies — but “dose” is something that’s not been very well studied. We don’t know very much about dose response. When it comes to exercise, you can think of dose as intensity (how hard people exercise), duration (how long they exercise), and frequency (how often someone exercises, let’s say in a given week). Then you can think of the exercise modality, where typically you break it up between either aerobic exercise, or strength training, or anaerobic exercise. When you look at these different parameters and the number of possible combinations, the perfect dose, in terms of what’s associated with the optimal benefits, hasn’t really been determined.

What we do know is that, when we looked at the studies for major depression, we found that most of them used something similar to the dose of physical activity that’s currently recommended by public health, in the United States at least. If you look at the Centers for Disease Control website, you find that the current public health dose is 150 minutes of moderate intensity exercise a week, or 75 minutes of vigorous intensity exercise per week, or a combination of those two. Then there is also a recommendation to engage in strength training. Well, when we looked at the literature, we found that most studies prescribed somewhere between that 75 minutes and 150 minutes per week of exercise. We came to the conclusion, at this point, that it seems reasonable to prescribe the public health dose.

Q: The idea of exercise prescription has been around for at least a decade. Have researchers looked at the intervention itself, to determine how much it really influences behaviour change?

A: Is prescribing exercise like that effective? I think the answer is likely not. That is, if you just tell people this is what your goal should be, are people going to do it? I think the research actually shows that many people remain sedentary even though they know they should meet those guidelines.

It’s usually the first thing that people ask when we talk about exercise for mood and anxiety disorders: can you get really people to do it? When you look at the statistics, let’s say sedentary rates in the United States, you see over the last decade a pretty flat line. So regardless of the fact that the prescription is out there, people who are sedentary have remained sedentary.

Just telling people to exercise is not going to do it. This is exactly why we devote a number of chapters in the book to talking about what else you might do to get yourself to meet that particular prescription.

Q: How do you create a supportive environment for someone?

A: I think there are a number of approaches. If you look at the literature on barriers to exercise, there are some that are more environmental, such as time or no access to a gym or not having the support. Some of those barriers are very useful to target, in the context of establishing a physical activity habit, such as getting people to change their environment, making sure that exercise is more accessible, putting it on your schedule. Also, building a support team — finding people around you who are interested in helping you develop a physical activity habit, like a buddy system.

The other thing we talk about in the book that’s unique about the prescription of exercise for mental health, relative to exercise for physical health, is that you can closely tie the behaviour, in this case getting to exercise, to the payoff. Usually the payoff is far in the future: people are told to exercise to have a longer and healthier life. For someone in their 30s, that may not have a lot of appeal. They may think, “Why should I work so hard now to feel much better down the road?” That’s often the challenge in getting people to change their behaviour. If there’s not an immediate payoff, people are less likely to be motivated to engage in exercise and to make it a consistent habit.

When it comes to exercising for mental health, there is an immediate payoff. Overcoming a mood or anxiety disorder may take longer — studies show that 12 to 16 weeks of exercise can yield really nice reductions in mood and anxiety symptoms — but one thing we know with exercise is that there is also an immediate effect. If you ask people to simply compare how they feel before exercise relative to after exercise, most people say they feel so much better. So that’s what we focus on to get people to establish this habit. That’s where the motivation comes in. If you exercise now and feel much better immediately after, then that’s why you should get excited about using exercise as your new method.

Q: Can you describe the approach you take to motivation?

A: Helping people see an immediate payoff is very important. When I work with people, I have them track their mood right before and right after exercise. If you’re not sure whether exercise is going to work for you, the test is a very simple one. You to ask the question, “Do I feel better after I exercise for 20 minutes?” Simply give yourself a rating and write it down on a piece of paper before you exercise. Do it on a scale from zero to 100, where zero means “I feel awful” and 100 means “I feel as good as it gets.” After you exercise, then write down that rating again. Do that a few times to get some evidence for this question, Does exercise help me feel better immediately?

That’s what we do in the beginning to get people hooked, so to speak, because this is an established finding. Many people don’t feel good during exercise, particularly if they exercise too hard. But regardless of how they feel during exercise, we know that the change pre- and post-exercise is evident in most people. People are often not aware of that, so that’s what we focus on initially. If people really get to see this, then they understand the principle. If you say no to exercise when you feel depressed or anxious, it’s similar to saying, “I’m not going to take an aspirin or ibuprofen when I have a headache.” Most of us do take aspirin or ibuprofen because we know that it helps us get rid of the headache. It’s important to help people see exercise as a tool to help them feel better now, as opposed to just feeling better in the future.

This is how we think about the exercise prescription for mood differently from the exercise prescription for health. But when it comes to motivation for exercise, much of it also happens beforehand. For example, when someone comes home from work and they’ve had a really hard day, they may be laying on the couch and thinking, ”Maybe I should watch some TV or maybe I should get something to eat,” and down there somewhere is this idea, “maybe I should also exercise,” but it’s very low on the hierarchy of motivations.

In the book, we talk about how in those situations you can shift your hierarchy so that exercise is on the top. Much of this has to do with changing your environment — that is, making sure that there are cues available that remind you of exercise, so you can get it higher on the hierarchy. Sometimes that means learning to take smaller steps. So when you’re laying there on the sofa and you’re thinking, “Maybe I should just watch TV,” one of the things you might do is, at least sit up first. Then you might say, “Well, I might not be ready to go exercise right now, but what I could do is at least get changed and maybe I’ll start wearing some of my exercise clothes and put on my shoes, and I guess I’ll sit on the sofa after I do that.” Then maybe you’ll do a couple of sit-ups or just walk around the house a little bit. Then you might open the door and say, “Well, maybe I’ll just walk around the block.” Once you walk around the block, then it’s easier to actually start thinking about jogging for a little bit. So rather than asking you to get up from the sofa and start running right away, which is so challenging for most people, think of it as small steps. This process of “chaining,” as we call, is more effective in helping people reach their goals.

A: Exactly. What we try to do is anticipate a lot of the motivational barriers that are very common when it comes to exercise. A lot of things can get in the way, and our technique is about helping people to start thinking differently. We try to identify what’s getting in the way — what maladaptive thoughts do people have, or what thoughts are getting people to move away from exercise as opposed to moving closer to exercise. Then we help them to start thinking differently so they can be more successful in achieving their goal.

Q: Earlier, you spoke about the importance of developing a support network, whether that’s coaching, or peer support, or a buddy system. How much does the support team need to know about these motivational techniques?

A: I think it’s really useful because much of it is just being aware of how motivation works. Many people think of motivation as something that you either have or you don’t, and that you have to be motivated first before you engage in the behaviour. It’s this idea that motivation precedes a behaviour change. But if you think about it that way, it’s a challenge because oftentimes people don’t have that motivation. It’s like they’re waiting for it. They’re looking for it, they’re digging for it, and they think, “Well, today I just don’t have the motivation, so maybe I'll exercise tomorrow.”

What we talk about in this book is the idea that motivation doesn’t always have to precede behaviour change. Oftentimes motivation comes after behaviour change. After you do something differently, after you engage in a behaviour, your motivation can actually change. So when you talk about a support network, when you want to help your buddies and when you want to help the people around you, I think it’s good to be aware of how motivation functions as it relates to behaviour.

Q: In addition to publishing the book, you’ve also created a website. What resources are available online?

A: In the book, we have a lot of worksheets that people can use. For example, I mentioned this idea of tracking your mood before and after exercise just to build some evidence that this works for people. That worksheet is available online. There are other resources, such as how you go about selecting a target heart rate and what that actually means. For example, when you talk about “moderate intensity” exercise, what does that translate into in terms of your heart rate? We have a table online so people can look it up for themselves. People can download these resources as separate sheets, as opposed to writing in the book.

Q: Is there a key message in the book that you’d like to emphasize?

A: We know that most people are physically inactive. What I think is key about this book, and something we’re excited about, is that prescribing exercise for mood is quite different than prescribing exercise for health. Exercise is almost guaranteed to produce an immediate positive effect, and that makes the prescription very different. People can more easily get excited about using exercise because they actually see the direct payoff. That’s one of the key messages of the book that will be helpful to get out there.

For more information about Exercise for Mood and Anxiety: Proven Strategies for Overcoming Depression and Enhancing Well-Being, visit www.exercise4mood.com.

Minding Our Bodies is an initiative of the Canadian Mental Health Association, Ontario, in partnership with Mood Disorders Association of Ontario, Nutrition Resource Centre, YMCA Ontario, and York University's Faculty of Health with support from the Ontario Ministry of Health Promotion.